The role of potential mediators in racial inequalities in tooth loss: the Pró-Saúde study

Systematic review of longitudinal studies on the association between cluster of health-related behaviors and tooth loss among adults

OBJECTIVES

To systematically review longitudinal studies on the association between cluster of/multiple health-related behaviors and tooth loss among adults.  Materials and methods: Inclusion criteria were prospective and retrospective longitudinal studies; adults; multiple or cluster of behaviors; tooth loss, one or more tooth lost and complete tooth loss. Exclusion criteria were intervention studies; cross-sectional studies; case-control studies; children under 18 years-old; single behavior. Two reviewers searched three databases up to April 2023. Open Grey and Google Scholar were searched for grey literature.  Results: Twelve longitudinal studies were included in this review. Nine studies had good quality, two had poor quality, and one had fair quality according to New-Castle-Ottawa Scale. According to ROBINS-E tool, nine studies were judged as moderate risk of bias while two studies were at low risk of bias and one study had serious risk of bias. One study assessed cluster of behavior, while others examined a number of separate health-related behaviors in relation to tooth loss. Meta-analysis was not feasible because of the high heterogeneity in exposure, measure of outcomes, covariates, sample size, and follow-up time. The research found an association between tooth loss and oral hygiene practices (two studies), dental attendance (four studies), smoking (six studies), and alcohol consumption (three studies).  Conclusion: This review provides evidence of a longitudinal association between cluster of/multiple health related-behaviors and tooth loss.

Association between racial iniquities and oral health status: a systematic review

The present study aimed to investigate the association between racial iniquities and oral health status. This is a systematic review with a protocol registered on the Prospero Platform (CRD42021228417), with searches carried out in electronic databases and in gray literature. Our study identified 3,028 publications. After applying the eligibility criteria and risk of bias analysis, 18 studies were selected. The results indicate that individuals of black/brown race/skin color have unfavorable oral health conditions, mainly represented by self-rated oral health, tooth loss, caries, and periodontitis. The results showed racial iniquities in oral health in different countries, for all analyzed indicators, with a greater vulnerability of the black population.

Discrimination and dental students: What is the reality in Brazilian institutions?

INTRODUCTION

This study aimed to evaluate whether there is discrimination in the dental educational environment, assess the main reasons for the discriminatory events, and if there is an association between discriminatory episodes and sociodemographic characteristics of undergraduate dental students.

MATERIALS AND METHODS

This observational cross-sectional study was conducted with a self-administered questionnaire to students enrolled in three Brazilian dental schools. Questions included sociodemographic characteristics and the occurrence of discriminatory episodes in the dental academic environment. Descriptive analysis was performed in RStudio 1.3 (R Core Team, RStudio, Inc., Boston, USA) software and the associations were tested using Pearson's chi-square test, considering 95% confidence intervals.

RESULTS

A total of 732 dental students were included, with a response rate of 70.2%. The vast majority of students were female (66.9%), with white/yellow skin colour (67.9%), and with a mean age of 22.6 (SD 4.1) years. Sixth-eight percent of students reported having experienced some discrimination in the academic environment and most reported feeling uncomfortable with the episode. The main reasons to have been discriminated against raised by students were specific behaviour/habit, have specific moral, ethical, and aesthetic values, gender, and socioeconomic status or social class. The occurrence of discriminatory episodes was associated with female gender (p = .05), non-heterosexual sexual orientation (p < .001), studying in public institutions (p < .001), receiving an institutional scholarship (p = .018), and being in the final undergraduate cycle (p < .001).

CONCLUSION

The occurrence of discriminatory episodes was common in Brazilian dental higher education. Discriminatory situations generate traumas and psychological marks, causing a loss of diversity within the academic environment that leads to loss of productivity, creativity, and innovation. Thus, strong institutional policies against discrimination are crucial to create a healthy dental academic environment.

Racial inequality in complete dental prosthesis delivered: can public services reduce inequities?

OBJECTIVES

To investigate the association between access and delivery of complete dental prosthesis according to the proportion of the black population in Brazilian municipalities and to oral health policies.

MATERIALS AND METHODS

Ecological data from 2017 to 2021 relating to the delivery of complete dentures stratified by race was collected in all Brazilian cities. We calculated a racial inequality indicator by subtracting the percentage of the black population from the percentage of complete dental prostheses that were delivered to blacks in each municipality. Logistic and linear regression models were carried out.

RESULTS

We found that 49.2% (2737) of municipalities delivered complete prostheses. The service was more frequently available in municipalities where black individuals made up 20-80% (odds ratio [OR] = 1.45, 95% confidence interval [CI] 1.15; 1.81), those with dental specialty centers (DSC) (OR = 3.04, 95%CI 2.50; 3.68), and those with more oral health teams (OHTs) (OR = 3.43, 95%CI 2.81; 4.18). Where dental prostheses were available, racial inequities favored the white population by 7.7 percentage points (p < 0.01). Increased inequality was observed in municipalities with more OHTs and/or a higher proportion of black individuals (>80%).

CONCLUSIONS

Although municipalities with a DSC, and with more OHTs offer better access to complete dental prosthesis for blacks, racial inequality still impacts the delivery of the service. Primary and secondary healthcare services may even exacerbate this.

CLINICAL RELEVANCE

Policymakers should monitor racial inequities in healthcare services. The currently unmet needs of black people are critical, especially in cities with more OHTs and/or increased proportions of black people.

Research on racial/ethnic inequities in oral health over the past 80 years: The role of racism

AIM

This study aims to (1) describe trends in explanations provided for racial/ethnic inequities in dental caries and periodontitis, and (2) explore the patterns of relatedness among explanations for these inequities.

MATERIALS AND METHODS

Highly cited publications based on studies indexed in the Scopus database were retrieved and assessed for eligibility. Explanations for racial/ethnic inequities were classified into eight different, but interrelated domains. We assessed trends and examined the relations among explanations using multiple correspondence analysis.

RESULTS

A total of 200 articles among the most cited publications were selected. The proportion of studies invoking racism as an explanation for racial inequities in oral health increased from 0% to 14.3%, from 1937 to 2020. The proportions of individual socio-economic factors increased from 52.0% to 82.9%, and dental care from 28.0% to 62.9%. The remaining explanations were stable: psychological/behavioural processes (62.5%), biological factors (49.5%), contextual/area-level effects (24.0%) and immigrant paradox (4.0%). Multiple correspondence analysis revealed a smaller axial distance between racism and the following categories: studies from Brazil, recent publications and Blacks/Hispanics/mixed-race groups. Publications about immigrants were axially closer to the high-income countries category.

CONCLUSIONS

Our findings call on dental researchers to consider racism as a cause for existing racial/ethnic inequities in oral health.

Discrimination and Dignity Experiences in Prior Oral Care Visits Predict Racialized Oral Health Inequities Among Nationally Representative US Adults

Racism, an oppressive and fallacious sociopolitical hierarchy, is a fundamental cause of oral health inequities worldwide. Everyday discrimination is associated with worse self-rated oral health, toothache and adult tooth loss, and lower oral care utilization. Few studies examine discrimination or microaggressions within oral care settings or their effects on oral health outcomes. We adapted the seven-item Everyday Discrimination Scale to the oral care setting (EDSOC); developed a four-item Dignity in Oral Care Scale (DOCS); fielded them to a probability-based nationally representative sample of US households as part of the 2022 State of Oral Health Equity in America survey (SOHEA, n = 5682); and examined associations between EDSOC and DOCS scores and three outcomes: self-rated oral health, duration since last oral care visit, and planning for future preventive/routine oral care. Nearly, all EDSCOC and DOCS measures were significantly associated with oral health outcomes. Discrimination experience in dental settings had an additive effect on reporting fair/poor oral health and a suppressive effect on planning a future dental visit. Indignity experience doubled-to-quadrupled the likelihood of reporting fair/poor oral health, not having visited a dentist in 2 years, and not planning a future oral care visit. Racio-ethnically minoritized patients may experience the unjust double bind of resolving urgent dental or completing preventive services needs amidst being treated in a discriminatory manner or without dignity. Oral health stakeholders should invest more effort to understand relationships between racism and oral health outcomes and introduce evidence-based interventions to ultimately abolish this societal harm.

Role of behavioural and age-related factors in the long-term impact of tooth loss on oral health-related quality of life: A 25-year follow-up of Swedish older adults

OBJECTIVES

The primary aim of this study was to assess any long-term association between tooth loss at age 50 and subsequent impaired oral health-related quality of life, OHRQoL, at age 65, 70 and 75, adjusted for time invariant socio-demographic-and time variant behavioural and age-related factors in terms of disadvantages with functional, social, health and psychological concerns. As a second aim, this study examined whether behavioural- and age-related factors played a role in explaining any long-term association between early tooth loss and subsequent OHRQoL.

METHODS

In 1992, 6346 residents, aged 50, consented to participate in a prospective cohort study and 3060 completed postal questionnaire follow-ups every fifth year (six in total) until 2017. Information on tooth loss was assessed at baseline at age 50. Behavioural- and age-related covariates were assessed repeatedly at ages 65, 70 and 75. OHRQoL was the repeated outcome measure assessed by the Oral Impact on Daily Performance, OIDP at age 65, 70 and 75. Generalized Estimating Equations, GEE, with binomial logit function was used to test the association between tooth loss and prevalence of oral impacts (OIDP) adjusting for counfounders and potential mediators. The role of behavioural and age-related factors in explaining the association between early tooth loss and OHRQoL was tested using the change in estimate approach.

RESULTS

Tooth loss and time variant behavioural- and age-related covariates associated independently with higher odds of impaired OHRQoL across time. The long-term impact of tooth loss seemed to be partly explained by time variant covariates related to functional and psychological concerns. Participants who had excessive tooth loss at age 50 were 2.5 times more likely to experience oral impacts before adjustment of covariates. After adjustment of functional- and psychological-covariates, participants were, respectively, 1.6 times and 1.4 times more likely to experience oral impacts.

CONCLUSION

This study revealed that early tooth loss at age 50 was independently associated with subsequent impaired OHRQoL at ages 65, 70 and 75. The aspects of behavioural- and age-related factors in terms of disadvantages in functional and psychological concerns seemed to play a role in explaining the long-term impact of tooth loss on impaired OHRQoL. A mid-life approach to the prevention of tooth loss for the protection of subsequent adverse health outcomes should guide health promotion interventions and also be recognized by oral health care providers both for patient interaction and clinical decision making.

Perceived experiences of racism linked to dental fear and anxiety among Black women

OBJECTIVES

Dental fear and anxiety are known determinants of delaying or avoiding dental care and vary considerably based on factors such as age and gender. However, little is known about dental fear and anxiety in racial/ethnic minority populations, which bear a disproportionate burden of poor oral health outcomes. Structural and social pathways responsible for producing these disparities are also understudied. Experiences of racism over the lifecourse may contribute to poor oral health outcomes through a pathway of dental fear and anxiety. This paper aimed to evaluate perceived experiences with racism, dental fear and anxiety, and the utilization of dental services, in the Black Women's Health Study (BWHS), a United States-based prospective cohort.

METHODS

Analysis of prospective data obtained from a geographic subset of participants in the BWHS was conducted. In 2014, BWHS participants residing in Massachusetts responded to a mailed oral health questionnaire that included the Index of Dental Anxiety and Fear (IDAF-4C+) instrument (N = 484; 69% response rate). Previously collected demographic and health information, along with reported experiences of everyday and lifetime racism, obtained from national BWHS questionnaires between 1995 and 2009, were merged with the Massachusetts-based sub-sample. Associations between high dental anxiety (HDA) (mean IDAF-4C+ score ≥2.5 on the dental fear and anxiety module) and oral health outcomes and perceived racism and HDA were explored via prevalence ratios (PR) calculated using log-binomial regression models, including adjustment for potential confounders.

RESULTS

Reported exposures to everyday racism occurred weekly on average for the top 25% of the sample, while 13% of participants reported exposure to multiple (n = 3) experiences of unfair treatment due to their race over their lifetime. HDA was prevalent among 17.8% of the sample and was significantly associated with indicators of poor oral health status. High exposures to everyday and lifetime experiences of racism were positively associated with HDA (PR = 1.08; 95% CI: 0.90, 1.58 and PR = 1.72; 95% CI: 1.03, 2.88, respectively).

CONCLUSIONS

Significant associations between racism and HDA, and between HDA and poor oral health and reduced utilization of dental care were observed. Dental anxiety may be a pathway through which perceived experiences with racism may impact oral health outcomes.

The dentist-patient relationship and oral health-related quality of life among older adults: A cohort study

OBJECTIVES

To assess the association between aspects of the dentist-patient relationship at age 65 and Oral Impacts on Daily Performances (OIDP) at ages 65 and 70 and to examine whether dental avoidance behaviours play a role in explaining that association.

BACKGROUND

Information about the quality of the dentist-patient relationship is important for dental care provision and healthy ageing.

METHOD

Secondary data analysis of a cohort study of Norwegians born in 1942. The participation rate in 2007 (age 65) and 2012 (age 70) was, respectively, 58.0% (n = 4211) and 54.5% (n = 3733). A total of 70.0% (n = 2947) of the baseline participants responded in 2012. Dentist-patient relationship aspects were assessed in terms of communication with the dentist, satisfaction with dental care, unpleasant experiences and changes of dentist. Generalised Estimating Equations (GEEs) were used to account for repeated measurements.

RESULTS

Prevalence of oral impacts (OIDP) was 29.0% in 2007 and 28.4% in 2012. Participants who received communication on oral hygiene during dental visits had a higher likelihood, whereas participants who reported satisfaction with dental care, no unpleasant experience and did not change dentist had a lower likelihood of reporting oral impacts over these 5 years. Corresponding odds ratios were: 1.2 (95% CI 1.0-1.5), 0.4 (95% CI 0.3-0.5), 0.6 (95% CI 0.5-0.7) and 0.5 (95% CI 0.3-0.6). Associations between dentist-patient relationship aspects and OIDP remained unchanged after adjustment for avoidance behaviours.

CONCLUSION

Training dentists in relationship skills might improve social interaction with patients and the oral health-related quality of life of older people in Norway.

Racial discrimination, self-efficacy, and oral health behaviours in adolescents

To examine the mediation effect of discrimination on the association of self-efficacy and oral health behaviours among adolescents. A cross sectional study of adolescents aged 12 to 18 years who were recruited from the University outpatient dental clinic were asked to complete a questionnaire consisting of: demographics (12 items), oral health behaviours (7 items), general self-efficacy (10 items) and self-efficacy for self-care (SESS, 15 items). Perceived discrimination was assessed if the adolescent had ever been treated unfairly based on their race. Perceived discrimination was assessed if the adolescent had ever been treated unfairly based on their race. Using pathway analyses, the relationship between oral health behaviours, self-efficacy, and discrimination was explored. Mediation and hierarchal logistic regression analyses were conducted. Of 252 participants, mean (SD) age was 14 (1.8) years old. 60% were female, 81% were born in Canada, 56% identified themselves as White, and 20% perceived discrimination. Mean score of all task-specific self-efficacies were significantly different within respective oral health behaviour categories (P-value <0.001). Of demographics, age and ethnicity (White) were significantly associated with discrimination (OR = 1.25: 95% CI; 1.06-1.48 and OR = 0.29: 95% CI; 0.15-0.55, respectively). Perceived discrimination was positively associated with higher sugar consumption and mediate the association between diet self-efficacy and adolescent's dietary behaviour. Significant mediation effect of perceived discrimination on the association of diet specific self-efficacy and diet oral health behaviour was observed. Oral health behaviours were self-reported which may have influenced the results.

Reflections on oral health inequalities: Theories, pathways and next steps for research priorities

Health inequalities, including those in oral health, are a critical problem of social injustice worldwide, while the COVID-19 pandemic has magnified previously existing inequalities and created new ones. This commentary offers a summary of the main frameworks used in the literature of oral health inequalities, reviews the evidence and discusses the potential role of different pathways/mechanisms to explain inequalities. Research in this area needs now to move from documenting oral health inequalities, towards explaining them, understanding the complex mechanisms underlying their production and reproduction and looking at interventions to tackle them. In particular, the importance of interdisciplinary theory-driven research, intersectionality frameworks and the use of the best available analytical methodologies including qualitative research is discussed. Further research on understanding the role of structural determinants on creating and shaping inequalities in oral health is needed, such as a focus on political economy analysis. The co-design of interventions to reduce oral health inequalities is an area of priority and can highlight the critical role of context and inform decision-making. The evaluation of such interventions needs to consider their public health impact and employ the wider range of methodological tools available rather than focus entirely on the traditional approach, based primarily on randomized controlled trials. Civil society engagement and various advocacy strategies are also necessary to make progress in the field.

Conceptualizing inequities and oppression in oral health research

Major sociohistorical processes have profound effects on oral health, with impacts experienced through structural oppression manifested in policies and practices across the lifespan. Structural oppression drives oral health inequities and impacts population-level oral health. In this global perspective paper, we challenge old assumptions about oral health inequities, address misleading conceptualizations in their description and operation and reframe oral health through the lens of intersecting systems of oppression. Furthermore, we emphasize the need for oral health researchers to explore causal pathways through which oppression harms oral health and engage in social science concepts to understand the root causes of oral health inequities fully. Finally, we call on policymakers, dental scholars and decision makers to consider health equity in all policies and to take a systems-oriented approach to effectively address oral health inequities.

Intersectional Discrimination Index: Initial stages of cross-cultural adaptation to Brazilian Portuguese

OBJECTIVE

To perform the cross-cultural adaptation of Intersectional Discrimination Index (InDI) into Brazilian Portuguese. InDI assesses the health impacts of intersectional experiences with anticipated (InDI-A), day-to-day (InDI-D), and major (InDI-M) discrimination.

METHODS

The following steps were taken: (1) independent translations; (2) synthesis of translations; (3) evaluation by an expert committee; (4) analysis by members of the target population; (5) back translation; and (6) pre-test. Based on the evaluation by the expert committee, the content validity coefficient (CVC) was calculated for each item and for the entire instrument. CVC helped identify which items needed adjustments according to the criteria of language clarity, theoretical relevance, and practical relevance.

RESULTS

Of the 31 items, 24 were considered adequate and seven required further language adjustments. CVC values were satisfactory for clarity (CVCt=0.86), practical relevance (CVCt=0.87), and theoretical pertinence (CVCt=0.87); a good level of understanding was reported by the target population (mean=4.44; standard deviation=1.36). The average response time was 15.5 minutes, and no additional difficulties in interpreting the items were reported. The back-translated InDI was approved by the original authors of the instrument.

CONCLUSION

The initial stages of the cross-cultural adaptation process showed that the use of InDI looks promising in Brazil. Further studies still need to examine the psychometric properties of the instrument to confirm the positive results of our work, as well as its usefulness for assessing the health impacts of intersectional experiences with discrimination.

Race (black-white) and sex inequalities in tooth loss: A population-based study

The effect of health inequalities is determined by different socioeconomic, sex, and race conditions. This study aimed to analyze the association of tooth loss with race (defined by self-reported skin color) and sex. Based on the hypothesis that the association between tooth loss and race may be modified by sex, we also aimed to evaluate possible interactions between race and sex in association with this event, in a population-based study in the city of Campinas, Brazil. A directed acyclic graph was used to select covariates. The prevalence, of tooth loss was 19% higher in black women compared to white men (Prevalence ratio [PR]: 1.19; 95%CI: 1.05–1.34). Moreover, the prevalence of tooth loss in black women was 26% higher than in white women (PR: 1.26; 95%CI: 1.13–1.42); and, within the strata of black people, black women had 14% higher dental loss (PR: 1.14; 95%CI: 1.02–1.27) compared to black men. This study found a significant interaction between race and sex in tooth loss, with a disadvantage for black women. In addition, this work contributes to the discussion of health inequities and can support policies for the provision of universal dental care.

Perceived racial discrimination partially mediates racial-ethnic disparities in dental utilization and oral health

Objectives

Perceived racial discrimination has been associated with poor health outcomes, yet its impact on oral health disparities is not understood. We examine the role of perceived racial discrimination in healthcare settings in explaining racial‐ethnic disparities in dental visits and tooth loss.

Methods

We used behavioral risk factor surveillance system (BRFSS) data for 2014 from four diverse states (AZ, MN, MS and NM) that included “reactions to race” module. Using Poisson regression to estimate risk ratios, we employed inverse odds ratio(IOR)‐weighted estimation for mediation analyses to estimate the role of perceived discrimination, after equalizing other confounders and risk factors.

Results

We found that among those with similar risk factors, those who experienced racial discrimination were 15% less likely to visit a dentist, and 12% more likely to have tooth loss than those who were treated same as other races. Both Hispanics and non‐Hispanic Blacks were 26% less likely to visit a dentist (for Hispanics, RR = 0.74, 95%CI: 0.69–0.78; for non‐Hispanic Blacks, RR = 0.74, 95%CI: 0.70–0.79), and non‐Hispanic Blacks were 36% more likely to have tooth loss relative to non‐Hispanic Whites with similar risk factors (RR = 1.36, 95%CI: 1.28–1.45). Perceived discrimination appears to contribute to racial‐ethnic disparities in dental utilization among Hispanics, and disparities in tooth loss among non‐Hispanic Blacks, relative to non‐Hispanic Whites.

Conclusions

Perceived racial discrimination partially explains the racial‐ethnic disparities in dental utilization and tooth loss among those who otherwise share the same risk factors for these outcomes. Addressing discrimination and systemic racism can reduce the racial‐ethnic disparities in oral health.

Etapas iniciais da adaptação transcultural do Intersectional Discrimination Index para o português do Brasil

RESUMO Objetivo: O presente estudo realizou a adaptação transcultural do Intersectional Discrimination Index (InDI) para o português do Brasil. Trata-se de um instrumento composto de 31 itens, que visa mensurar os impactos para a saúde de experiências interseccionais com discriminação antecipada (InDI-A), cotidiana (InDI-D) e maior (InDI-M). Métodos: Foram percorridas as seguintes etapas: (1) traduções independentes; (2) síntese das traduções; (3) avaliação por comitê de especialistas; (4) análise por membros da população-alvo; (5) tradução reversa; e (6) pré-teste. Calculou-se igualmente o coeficiente de validade de conteúdo (CVC) de cada um dos itens e de todo o instrumento. O CVC foi empregado por permitir identificar quais itens necessitavam de ajustes de acordo com os critérios de clareza de linguagem, relevância teórica e pertinência prática. Resultados: Dos 31 itens do instrumento, 24 foram considerados adequados e sete necessitaram de ajustes de linguagem. Os valores dos CVC foram satisfatórios para os critérios de clareza de linguagem (CVCt=0,86), pertinência prática (CVCt=0,87) e relevância teórica (CVCt=0,87), e o público-alvo considerou satisfatória a compreensão do instrumento (média=4,44; desvio padrão=1,36). O tempo médio de resposta foi de 15,5 minutos e não foram registradas dúvidas adicionais. A tradução reversa foi aprovada pelos autores originais do instrumento. Conclusão: As etapas iniciais do processo de adaptação transcultural mostraram que o InDI parece promissor para uso no Brasil. Estudos futuros ainda precisam examinar as propriedades psicométricas do instrumento para confirmar os resultados positivos do presente trabalho, bem como sua utilidade para a avaliação dos impactos para a saúde de experiências interseccionais com discriminação.

Influence of socioeconomic status on oral disease burden: a population-based study

Background

Dental caries is associated with Biological, behavioral, socioeconomic, and environmental factors; however, socioeconomic status is a distal determinant of dental caries development that modulates exposure to risk and protective factors. This study aimed to analyze the socioeconomic factors associated with the concentration of oral diseases in a population-based study in Brazil.

Methods

This is a quantitative, analytical, cross-sectional study based on secondary data from the SB São Paulo 2015 epidemiological survey. A total of 17,560 subjects were included. The concentration of oral disease in the population was estimated by the oral disease burden (ODB) variable. The ODB consists of four components: dental caries; tooth loss; need for dental prosthesis and periodontal condition. Thus, the total score on the ODB could vary between 0 and 4, with the highest score indicating the worst possible situation. ODB was analyzed in multivariate negative binomial regression, and multivariate binary logistic regression analysis. The following factors were included as independent variables: age group, skin color, socioeconomic factors, family income and Oral Impact on Daily Performance (OIDP).

Results

In the sample, 86.9% had no minimum ODP component. Negative multivariate binomial regression showed a statistically significant relationship (p < 0.005) between ODB and all variables analyzed (skin color, family income, education, OIDP results and age range). The adjusted multivariate binary logistic regression showed that the individuals most likely to have at least one component of ODB were nonwhite (25.5%), had a family income of up to R$ 1500.00/month (19.6%), had only completed primary education (19.1%), and reported that their oral health had an impact on their daily activities (57.6%). Older adults individuals were two times more likely than adolescents to have an ODB component.

Conclusions

ODB is associated with factors related to social inequality. Adults and older adults individuals had the highest cumulative number of ODB components.

Is Racial Discrimination Associated with Number of Missing Teeth Among American Adults?

OBJECTIVE

The objectives of this study are to assess the association of racial discrimination with tooth loss among American adults and whether this relationship, if existed, explains ethnic differences in tooth loss.

METHODS

Data is from the Behavioural Risk Factor Surveillance System (BRFSS) 2014, a cross-sectional survey of a nationally representative sample of American adults. The survey included data on sociodemographic characteristics, behaviour, health insurance and number of missing teeth. The survey also included questions on whether a person was treated differently because of his/her race. Logistic regression analysis was conducted to assess the relationship between tooth loss and indicators of discrimination. We also examined the relation between ethnicity and indicators of discrimination.

RESULTS

The analysis included 4858 participants aged 18 to 44 years. Tooth loss (> one tooth) was reported by 26% of participants. Among those reporting discrimination at healthcare facility, there was 141% increase in tooth loss compared to those not reporting discrimination. Discrimination at work and emotional impact of discrimination were both significantly associated with tooth loss in the partially adjusted models. Accounting for discrimination slightly attenuated ethnic differences in too loss. Black Americans had significantly higher odds for reporting all types of discrimination used here.

CONCLUSION

This study demonstrated a potential role for discrimination in tooth loss among American adults. Discrimination could also explain part of ethnic inequalities in oral health.

Social Mobility and Tooth Loss: A Systematic Review and Meta-analysis

This study systematically reviews the evidence of the association between life course social mobility and tooth loss among middle-aged and older people. PubMed, Scopus, Embase, and Web of Science were systematically searched in addition to gray literature and contact with the authors. Data on tooth loss were collated for a 4-category social mobility variable (persistently high, upward or downward mobility, and persistently low) for studies with data on socioeconomic status (SES) before age 12 y and after age 30 y. Several study characteristics were extracted to investigate heterogeneity in a random effect meta-analysis. A total of 1,384 studies were identified and assessed for eligibility by reading titles and abstracts; 21 original articles were included, of which 18 provided sufficient data for a meta-analysis with 40 analytical data sets from 26 countries. In comparison with individuals with persistently high social mobility, the pooled odds ratios (ORs) for the other categories were as follows: upwardly mobile, OR = 1.73 (95% CI, 1.53 to 1.95); downwardly mobile, OR = 2.52 (95% CI, 2.19 to 2.90); and persistently low, OR = 3.96 (95% CI, 3.13 to 5.03). A high degree of heterogeneity was found(I² > 78%), and subgroup analysis was performed with 17 study-level characteristics; however, none could explain heterogeneity consistently in these 3 social mobility categories. SES in childhood and adulthood is associated with tooth loss, but the high degree of heterogeneity prevented us from forming a robust conclusion on whether upwardly or downwardly mobile SES may be more detrimental. The large variability in effect size among the studies suggests that contextual factors may play an important role in explaining the difference in the effects of low SES in different life stages (PROSPERO CRD42018092427).

Racial and regional inequalities of dental pain in adolescents: Brazilian National Survey of School Health (PeNSE), 2009 to 2015

The aim of the study is: (a) investigate the racial inequalities as one specific dimension that affects dental pain in Brazilian adolescents; and (b) investigate the regional variations of dental pain. This cross-sectional study used data from Brazilian National Survey of School Health (PeNSE), carried out with adolescents in 2009, 2012 and 2015. Dental pain was evaluated through the question: "Did you have dental pain in the last six months?". The main exposures were race and Brazilian regions, used to evaluate inequalities related to the outcome. Sex, age, school type and maternal education were used as covariables. The statistical significance of the trends in dental pain was tested using linear regression. The analysis was conducted in Stata 13.0 statistical package using the svy command. The standard prevalence of dental pain was 18.8%, 21.1% and 23.7%, showing an increasing trend over time (p < 0.001). We observed absolute inequalities in dental pain related to race and regions. A higher prevalence was found in non-white girls of public schools and in the Northern Region. The indexes of inequalities increased in the group of black girls, related to an increase of dental pain predominantly in girls whose mothers had lower educational level. It was observed that the prevalence of dental pain in Brazilian adolescents increased over time as well as its inequalities, which remained in marginalized populations and linked to Brazilian regions.

Influences of behaviour and attitude on education related inequality in tooth loss: findings from Norway and Sweden over 5 years of follow- up

OBJECTIVES

Following community dwelling cohorts in Norway and Sweden from 65 to 70 years, this study aimed to answer the following questions; Is there cross country variation in educational inequality in tooth loss between the Norwegian and Swedish cohorts? Does oral health behaviours and attitudinal beliefs play a role in explaining educational inequality in tooth loss across time and cohorts?

MATERIAL AND METHODS

In 2007 and 2012 Statistics Norway administered mailed questionnaires to all individuals born in 1942 in three counties. The response rate was 58% (n = 4211) in 2007 and 54.5% (n = 3733) in 2012. In Sweden the same questionnaires were sent to the 1942 cohort in two counties. The final response rate in 2007 and 2012 were respectively, 73.1% (n = 6078) and 72.2% (n = 5697).

RESULTS

In Norway, tooth loss prevalence was 21.8% in 2007 and 23.2% in 2012. Corresponding figures in Sweden were 25.9% and 27.3%. The prevalence of tooth loss was higher among lower than higher educated participants and the gradient was significantly weaker in Sweden than in Norway. Multiple variable analyses adjusting for oral behavioural and attitudinal variables attenuated education related gradients in both cohorts.

CONCLUSION

Education related inequality in tooth loss was stronger in the Norwegian than in the Swedish cohort across the survey years. Oral behaviours and attitudinal beliefs played a role in explaining the gradients across time. This illustrates a necessity to promote oral health enhancing behaviours and attitudinal beliefs, particularly so in lower educational groups.

Intersectionality, racial discrimination and oral health in Australia

BACKGROUND

There is a dearth of studies on the extent to which perceived racial discrimination shapes oral health. Following an intersectional perspective, we estimated the prevalence of perceived racial discrimination in Australia, its association with oral health impairment, and examined whether this association was more severe among low socioeconomic status (SES) groups.

METHODS

Data came from the 2013 National Dental Telephone Interview Survey (N = 2798), a population-based study of Australian adults. Multivariable Poisson regression models were estimated to test the relationship between perceived racial discrimination and self-reported oral health impairment, as well as to investigate whether the magnitude of this association was greater among low-SES respondents. Relative Excess Risks due to Interaction (RERI) were used to indicate the presence of potentially large discrimination effects within low-SES strata.

RESULTS

Racial discrimination in the past 12 months was reported by 11.5% of all participants. Australians reporting racial discrimination had 1.4 (95% CI 1.1, 1.7) times the prevalence of impaired oral health. The association between perceived racial discrimination and oral health impairment was stronger among low-SES groups. The RERI was 0.55, indicating a super-additive Effect Measure Modification (EMM) by income on the additive scale. Similar results were observed with the EMM analyses by educational attainment.

CONCLUSION

Our findings indicate that perceived racial discrimination, as a specific form of widespread inequality, is associated with higher frequencies of oral health impairment among Australian adults. We also suggest that socially marginalized groups bear a greater burden of the oral health effects of racial discrimination.

Geographical and socioeconomic inequalities in dental attendance among children in Peru: Findings from the Demographic and Family Health Survey 2017

OBJECTIVE

The aim of the study was to explore the presence of inequalities in the use of dental services among <12-year-old children residing in Peru, according to their wealth quintile and natural region of residence.

METHODS

This was a cross-sectional secondary data analysis of the 2017 Demographic and Family Health Survey of Peru (n = 39 881 children). Generalized Poisson regression models, adjusted for gender, age, maternal ethnicity, place of residence and health coverage, were used to study the association between wealth quintile and use of dental services followed by stratified models by the natural region (Metropolitan Lima, coast, Andes mountains and jungle) and predicted probability graphs to study the effect of the natural region on inequalities in the use of dental services.

RESULTS

Inequalities in the use of dental services among children were observed according to the wealth quintile and natural region. A social gradient was present in the Andes mountains, coast and jungle regions. The greatest inequalities were observed in the coast (richest vs poorest quintile PR = 1.81 95% CI = 1.56-2.11) and jungle regions (richest vs poorest quintile PR = 1.81 95% CI = 1.53-2.14). The jungle presented the lowest proportion of children using dental services, while Metropolitan Lima had the highest proportion. No significant differences were observed between wealth quintiles among children from Metropolitan Lima.

CONCLUSIONS

Differences in socioeconomic inequalities in the use of dental services among natural regions were observed. The distribution of dental centres and personnel, and the geographical and demographic characteristics of each region, may play an important role in the presence of the inequalities observed.

Advancing racial equity in oral health (research): more of the same is not enough

By critically appraising the literature on the oral health effects of race-based oppression, this focus article makes four recommendations that may both facilitate more nuanced research on the topic and mitigate racial/ethnic inequities in (oral) health. The first is recognizing that science itself may perpetuate racial/ethnic injustice, such that adopting a 'neutral' position must be replaced with actively fostering anti-racist narratives. The second is to not imply that racial oppression is bad because it harms oral health. Rather, studies should help build a fairer world, wherein oral health inequities would not abound. The third recommendation is encouraging initiatives that understand systems of oppression as conjointly operating to shape oral health. The fourth and final recommendation is taking race-based oppression as a multi-level system that operates on three inter-related conceptual levels - intra-personal, inter-personal, and structural. The extent to which scholars, practitioners, and policymakers are willing to follow these recommendations may determine how successful attempts to eradicate (oral) health inequities might be. Learning from, and avoiding mistakes made in, previous publications is one ethical pathway towards this end.

Early-life course factors and oral health among young Norwegian adults

OBJECTIVE

Using a national sample of young Norwegian adults, we examined whether unpleasant experience with dental care during childhood is associated with tooth loss and oral health-related quality of life in adulthood after accounting for early- and later-life socio-behavioural circumstances and dental avoidance behaviour.

METHODS

2433 individuals aged 25-35 years participated in an electronic survey. Oral quality of life was measured using the oral impact of daily performance (OIDP) inventory. Generalized linear models and negative binomial regression models were used to estimate the association of early unpleasant experiences with dental care and tooth loss and OIDP scores. Incidence rate ratio (IRR) and 95% confidence intervals (CI) were used to estimate the relative differences in prevalence of tooth loss and OIDP scores.

RESULTS

Adjusting for early-life characteristics only, the prevalence of tooth loss was 1.42 (IRR = 1.42, 95% CI: 1.24-1.64) and 1.96 (IRR = 1.96, 95% CI: 1.70-2.26) times higher among individuals who reported unpleasant experiences a few times or several times, than in individuals who did not report unpleasant experiences with dental care in childhood. Adjusting further for educational level, smoking and tooth brushing attenuated the relative differences (IRR = 1.40, 95% CI: 1.22-1.62 and IRR = 1.88, 95% CI: 1.62-2.17, respectively). Lastly, when adjusting for dental avoidance behaviour, the prevalence of tooth loss was 1.29 (IRR = 1.29, 95% CI: 1.11-1.50) and 1.58 (IRR = 1.58, 95% CI: 1.32-1.88) times higher among individuals who reported unpleasant experiences a few times or several times than in those who did not. Corresponding associations of early unpleasant experience with OIDP were (IRR = 1.41 95% CI: 1.22-1.63) and (IRR = 1.69, 95% CI: 1.42-2.01) when adjusting for early-life characteristics, and (IRR = 1.39, 95% CI: 1.20-1.60) and (IRR = 1.51, 95% CI: 1.27-1.80) when adjusting for education, smoking and tooth brushing. When adjusting for dental avoidance behaviour, the association of early unpleasant experience with OIDP became nonsignificant.

CONCLUSION

Unpleasant dental care experiences during childhood are associated with poor oral health in adulthood, independent of later-life socio-behavioural characteristics including negative dental care seeking. This highlights the importance of tailoring regular contacts with dental healthcare services in childhood to build confidence in children and thus has implications for healthcare policy.

Association Between Socioeconomic and Demographic Characteristics and Non-fatal Alcohol-Related Injury in Maringá, Brazil

Background: Previous research has corroborated a high burden of alcohol-related injury in Brazil and the presence of socioeconomic disparities among the injured. Yet, individual-level data is scarce. To fill this gap, we examined the association between demographic and socioeconomic characteristics with non-fatal alcohol-related injury in Maringá, Brazil.

Methods: We used household survey data collected during a 2015 cross-sectional study. We conducted univariate and multivariate analyses to evaluate associations of demographic (age, gender, race) and socioeconomic characteristics (employment, education, income) with non-fatal alcohol-related injury.

Results: Of the 995 participants who reported injuries, 62 (6.26%) were alcohol-related. Fifty-three (85%) alcohol-related injuries were reported by males. Multivariate analysis indicated being male (OR = 5.98 95% CI = 3.02, 13.28), 15–29 years of age (OR = 3.62 95% CI = 1.72, 7.71), and identifying as Black (OR = 2.38 95% CI = 1.09, 4.95) were all significantly associated with increased likelihood of reporting an alcohol-related injury, whereas unemployment was significantly associated with decreased likelihood of reporting an alcohol-related injury (OR = 0.41 95% CI = 0.18, 0.88).

Conclusion: Our findings suggest that in Maringá, being male, between the ages of 15 and 29, employed, or identifying as Black were characteristics associated with a higher risk for non-fatal alcohol-related injury. Individual level data, such as ours, should be considered in combination with area-level and country-level data when developing evidence-based public-health policies.

Racial inequalities in public dental service utilization: Exploring individual and contextual determinants among middle-aged Brazilian adults

OBJECTIVES

To investigate differences between Pardos (mixed) and Blacks with their White counterparts in the use of public dental service among a sample of Brazilian adults taking into consideration the role of individual and contextual characteristics.

METHODS

A total of 6196 adults aged 35-44 years were sampled from the 2010 Brazilian National Oral Health Survey and nested in one of 27 Brazilian State Capitals. Binary multilevel logistic analyses were conducted. Use of public dental service in the last visit was the outcome, and self-reported colour/race (Pardo, Black, White) was the explanatory variable. Individual covariates were sex, level of education, family income, self-reported need for treatment, dental pain in the last 6 months, presence of decayed, filled and missing teeth. The State Capital covariates were proportion of Pardos/Blacks, Human Development Index, Gini coefficient, Integration of dental teams into Brazil Family Health Program and dentist per population rate.

RESULTS

Pardos and Blacks were 1.25 (95% CI 1.10-1.42) and 1.73 (95% CI 1.41-2.11) times, respectively, more likely to visit the public dental service than Whites. Adjustments for level of education and income were more relevant in affecting the estimates between groups than any other covariate, but differences persisted. Colour/race was independently associated with the type of service used in the last dental visit after fully adjusted for individual and State Capital characteristics.

CONCLUSIONS

Racial differences in dental service utilization were evident for middle-aged adults in Brazil. The results found highlight the importance of investments in public dental service as Pardos and Blacks relied more on this type of service than Whites.

Health Inequalities amongst People of African Descent in the Americas, 2005-2017: A Systematic Review of the Literature

Ethnic inequalities are often associated with social determinants of health. This study seeks to identify the latest scientific evidence on inequalities in the health of people of African descent in the Americas. For this, a systematic review of the literature on health and people of African descent in the Americas was carried out in the LILACS, PubMed, MEDLINE, and IBECS databases. Institutional and academic repositories were also consulted. Evidence was obtained on the presence and persistence of health inequalities in the population of African descent in the Americas from the identification of five types of quantitative and qualitative evidence: (1) ethnic/racial concept and variables; (2) relations with other social determinants; (3) health risks; (4) barriers and inequalities in health services; and, (5) morbi-mortality from chronic diseases. Studies with qualitative methods revealed invisibility, stereotypes, and rejection or exclusion as main factors of inequality. This review evidenced the existence of health inequalities, its interconnection with other adverse social determinants and risk factors, and its generation and perpetuation by discrimination, marginalization, and social disadvantage. These conditions make people of African descent a priority population group for action on equity, as demanded by the 2030 Agenda for Sustainable Development.

Health insurance and education: major contributors to oral health inequalities in Colombia

BACKGROUND

Health inequalities, including inequalities in oral health, are problems of social injustice worldwide. Evidence on this issue from low-income and middle-income countries is still needed. We aimed to examine the relationship between oral health and different dimensions of socioeconomic position (SEP) in Colombia, a very unequal society emerging from a long-lasting internal armed conflict.

METHODS

Using data from the last Colombian Oral Health Survey (2014), we analysed inequalities in severe untreated caries (≥3 teeth), edentulousness (total tooth loss) and number of missing teeth. Inequalities by education, income, area-level SEP and health insurance scheme were estimated by the relative index of inequality and slope index of inequality (RII and SII, respectively).

RESULTS

A general pattern of social gradients was observed and significant inequalities for all outcomes and SEP indicators were identified with RII and SII. Relative inequalities were larger for decay by health insurance scheme, with worse decay levels among the uninsured (RII: 2.57; 95% CI 2.11 to 3.13), and in edentulousness (RII: 3.23; 95% CI 1.88 to 5.55) and number of missing teeth (RII: 2.08; 95% CI 1.86 to 2.33) by education, with worse levels of these outcomes among the lower educated groups. Absolute inequalities followed the same pattern. Inequalities were larger in urban areas.

CONCLUSION

Health insurance and education appear to be the main contributors to oral health inequalities in Colombia, posing challenges for designing public health strategies and social policies. Tackling health inequalities is crucial for a fairer society in a Colombian post-conflict era and our findings highlight the importance of investing in education policies and universal health care coverage.

Racial Discrimination and Uptake of Dental Services among American Adults

This study examined the relationship between racial discrimination and use of dental services among American adults. We used data from the 2014 Behavioral Risk Factor Surveillance System, a health-related telephone cross-sectional survey of a nationally representative sample of adults in the United States. Racial discrimination was indicated by two items, namely perception of discrimination while seeking healthcare within the past 12 months and emotional impact of discrimination within the past 30 days. Their association with dental visits in the past year was tested in logistic regression models adjusting for predisposing (age, gender, race/ethnicity, income, education, smoking status), enabling (health insurance), and need (missing teeth) factors. Approximately 3% of participants reported being discriminated when seeking healthcare in the past year, whereas 5% of participants reported the emotional impact of discrimination in the past month. Participants who experienced emotional impact of discrimination were less likely to have visited the dentist during the past year (Odds Ratios (OR): 0.57; 95% CI 0.44-0.73) than those who reported no emotional impact in a crude model. The association was attenuated but remained significant after adjustments for confounders (OR: 0.76, 95% CI 0.58-0.99). There was no association between healthcare discrimination and last year dental visit in the fully adjusted model. Emotional impact of racial discrimination was an important predictor of use of dental services. The provision of dental health services should be carefully assessed after taking account of racial discrimination and its emotional impacts within the larger context of social inequalities.

Unfair Treatment and Periodontitis Among Adults in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

This study investigates how perceived unfair treatment, towards self and observed towards others due to ethnicity, is associated with periodontitis among diverse Hispanic/Latino adults, accounting for sociodemographic, health behavior, and acculturation factors. Baseline (2008-2011) dental and survey data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a multicenter epidemiologic study, were analyzed (N = 12,750). Crude and adjusted prevalence ratios and confidence limits were estimated. Half (49%) reported never being treated unfairly, while 41% reported they were sometimes, and 10% reported it often/always. One third (32%) never saw others treated unfairly, while 42% reported it sometimes, and 26% reported it often/always. In the final fully adjusted model, the prevalence of periodontitis was higher among adults who were as follows: non-Dominican, older, male, had a past year dental visit, current and former smokers, and among those who observed unfair treatment towards others. Lower prevalence was associated with higher income, higher educational attainment, less than full-time employment, reporting experiencing unfair treatment, higher acculturation scores, and having health insurance. Perceived unfair treatment towards self was negatively associated with periodontitis prevalence, while observed unfair treatment towards others was positively associated with the outcome among diverse Hispanics/Latinos. The associations between unfair treatment and periodontitis warrant further exploration.

Racial Inequalities in Oral Health

Together with other social categories, race has been at the core of much scholarly work in the area of humanities and social sciences, as well as a host of applied disciplines. In dentistry, debates have ranged from the use of race as a criterion for the recommendation of specific dental procedures to a means of assessing inequalities in a variety of outcomes. What is missing in these previous discussions, though, is a broader understanding of race that transcends relations with genetic makeup and other individual-level characteristics. In this review, we provide readers with a critique of the existing knowledge on race and oral health by answering the following 3 guiding questions: (1) What concepts and ideas are connected with race in the field of dentistry? (2) What can be learned and what is absent from the existing literature on the topic? (3) How can we enhance research and policy on racial inequalities in oral health? Taken together, the reviewed studies rely either on biological distinctions between racial categories or on other individual characteristics that may underlie racial disparities in oral health. Amidst a range of individual-level factors, racial inequalities have often been attributed to lower socioeconomic status and “health-damaging” cultural traits, for instance, patterns of and reasons for dental visits, dietary habits, and oral hygiene behaviors. While this literature has been useful in documenting large and persistent racial gaps in oral health, wider sociohistorical processes, such as systemic racism, as well as their relationships with economic exploitation, social stigmatization, and political marginalization, have yet to be operationalized among studies on the topic. A nascent body of research has recently begun to address some of these factors, but limited attention to structural theories of racism means that many more studies are needed to effectively mitigate racial health differentials.

Normative prosthodontic care need: does it impact the daily life of young Saudis with high level of oral diseases? A cross sectional study

BACKGROUND

Assessing the need for prosthodontic care previously included older age groups. There is less information about younger populations who may need this care because of high disease levels. The aim of this study was to assess the normative need for prosthodontic care in a young Saudi population with high oral disease levels, the associated factors and its impact on daily life.

METHODS

A cross sectional study included Saudi adults in the Eastern Province in 2016. A questionnaire was used to assess personal background (confounders), risk factors affecting oral diseases (exposures) and the impact of oral problems on daily life. A clinical examination assessed tooth loss, the presence of prosthodontic appliances, the presence of untreated decay and need for periodontal care. Directed acyclic graphs identified the confounders to be included in regression models with separate outcomes: normative need for prosthodontic care (binary logistic model) and impact on 6 daily life aspects (ordinal regression models).

RESULTS

Complete data were available for 574/ 700 = 82% and 46.7% needed prosthodontic care with 2 lost teeth on average among adults of mean age = 33.2 years. The confounders controlled for the need for prosthodontic care included socioeconomic status (SES), dental visits last year and health insurance. The confounders for the impact on daily life included age and SES. In adjusted models, normative need for prosthodontic care was significantly associated with untreated decay (OR = 2.09, 95% C.I. = 1.37, 3.19). The impact on daily life was not significantly associated with prosthodontic care need but with untreated decay, especially sleeplessness (regression coefficient = 0.53, 95% C.I. = 0.02, 1.04) and dropping daily activities (regression coefficient = 0.79, 95% C.I. = 0.13, 1.46). In addition, the need for periodontal care was associated with food avoidance (regression coefficient = 0.73, 95% C.I. = 0.28, 1.18).

CONCLUSIONS

In Saudi adults in the Eastern Province, there was a considerable normative need for prosthodontic care due to untreated decay. The impact on daily life was related to the underlying oral diseases rather than the need for prosthodontic care itself.

Ethnic differences in oral health and use of dental services: cross-sectional study using the 2009 Adult Dental Health Survey

BACKGROUND

Oral health impacts on general health and quality of life, and oral diseases are the most common non-communicable diseases worldwide. Non-White ethnic groups account for an increasing proportion of the UK population. This study explores whether there are ethnic differences in oral health and whether these are explained by differences in sociodemographic or lifestyle factors, or use of dental services.

METHODS

We used the Adult Dental Health Survey 2009 to conduct a cross-sectional study of the adult general population in England, Wales and Northern Ireland. Ethnic groups were compared in terms of oral health, lifestyle and use of dental services. Logistic regression analyses were used to determine whether ethnic differences in fillings, extractions and missing teeth persisted after adjustment for potential sociodemographic confounders and whether they were explained by lifestyle or dental service mediators.

RESULTS

The study comprised 10,435 (94.6 %) White, 272 (2.5 %) Indian, 165 (1.5 %) Pakistani/Bangladeshi and 187 (1.7 %) Black participants. After adjusting for confounders, South Asian participants were significantly less likely, than White, to have fillings (Indian adjusted OR 0.25, 95 % CI 0.17-0.37; Pakistani/Bangladeshi adjusted OR 0.43, 95 % CI 0.26-0.69), dental extractions (Indian adjusted OR 0.33, 95 % CI 0.23-0.47; Pakistani/Bangladeshi adjusted OR 0.41, 95 % CI 0.26-0.63), and <20 teeth (Indian adjusted OR 0.31, 95 % CI 0.16-0.59; Pakistani/Bangladeshi adjusted OR 0.22, 95 % CI 0.08-0.57). They attended the dentist less frequently and were more likely to add sugar to hot drinks, but were significantly less likely to consume sweets and cakes. Adjustment for these attenuated the differences but they remained significant. Black participants had reduced risk of all outcomes but after adjustment for lifestyle the difference in fillings was attenuated, and extractions and tooth loss became non-significant.

CONCLUSIONS

Contrary to most health inequalities, oral health was better among non-White groups, in spite of lower use of dental services. The differences could be partially explained by reported differences in dietary sugar.

Functional Dentition in Brazilian Adults: An Investigation of Social Determinants of Health (SDH) Using a Multilevel Approach

OBJECTIVES

Estimate the prevalence of functional dentition among Brazilian adults using four different definitions and identify associated factors.

METHODS

A cross-sectional study was conducted involving 9564 Brazilian adults aged 35-44 years who participated in the 2010 National Oral Health Survey. Data collection involved oral examinations and the administration of questionnaires. The following definitions were used: 1-WHO Functional Dentition (FDWHO: ≥ 20 teeth present); 2-well-distributed teeth (WDT: ≥ 10 teeth in each arch); 3 -Functional dentition classified by esthetics and occlusion (FDClass5: dentitions that sequentially exhibit at least one tooth in each arch, at least 10 teeth in each arch, all maxillary and mandibular anterior teeth, three or four premolar posterior occluding pairs [POPs], and at least one molar POP bilaterally); 4-Functional dentition classified by esthetics, occlusion and periodontal status (FDClass6: corresponds to FDClass5 with the addition of periodontal status of all sextants in the oral cavity with, at most, shallow pockets and/or clinical attachment level of 5 mm (CPI ≤ 3 and/or CAL ≤ 1). The independent variables were individual factors (gender, self-declared skin color, schooling, monthly household income, age group, self-rated treatment need, dental pain, dental appointment in the previous 12 months and dental services) and contextual factors (Municipal Human Development Index [MHDI]), Gini coefficient, fluoridated water supply and oral health coverage). Multilevel mixed-effect Poisson regression analyses were performed.

RESULTS

The prevalence of functional dentition based on the FDWHO, WDT, FDClass5 and FDClass6 definitions was 77.9%, 72.9%, 42.6% and 40.3%, respectively. Adults with ≥12 years of schooling and monthly household income from US$ 853 to 2557 had higher prevalence rates of FDWHO (PR: 1.41 and 1.10, respectively), WDT (PR: 1.58 and 1.14, respectively), FDClass5 (PR: 2.03 and 1.27, respectively) and FDClass6 (PR: 2.15 and 1.35, respectively). These values in the final models were adjusted for gender, self-declared skin color (FDClass5), age group, self-rated treatment need (FDWHO, FDClass5 and FDClass6), dental appointment in the previous 12 months (FDWHO and WDT), dental services (FDWHO and WDT) and contextual factors. A very high MHDI and presence of fluoridated water supply were associated with higher prevalence rates of the four outcomes.

CONCLUSIONS

The incorporation of the criteria of new definitions of functional dentition led to a lower prevalence rate among Brazilian adults. Striking individual and contextual inequalities were identified with regard to the four definitions analyzed, which need to be addressed through inter-sector efforts.

Assessing mediators between discrimination, health behaviours and physical health outcomes: a representative cross-sectional study

PURPOSE

Discrimination is a social determinant of health; however, the pathways linking discrimination to ill-health are under-researched. This study investigated the mediators through which discrimination affects health behaviours and physical health outcomes, as well as assessed whether sex moderated these mechanisms.

METHODS

Data from a representative survey (n = 1023) of undergraduate students enrolled in a Brazilian university in 2012 were used. Structural equation models were applied to assess the following mediation mechanisms--(1) discrimination influences self-rated health and body mass index via anxiety/depression; (2) discrimination affects behaviours (alcohol consumption, problem drinking, smoking, fruit/vegetable consumption, and physical activity) through discomfort associated with discriminatory experiences. The potential of sex to act as an effect-modifying variable was also explored in each of the postulated pathways.

RESULTS

The effect of discrimination on self-rated poor health was totally (100.0%) mediated by anxiety/depression, while body mass index was not correlated with discrimination. Self-reported discrimination was associated with some behaviours via discomfort. Particularly, discomfort partially mediated the positive association between discrimination, leisure time physical activity (43.3%), and fruit/vegetable consumption (52.2%). Sex modified the association between discrimination, discomfort and physical activity in that such mechanism (more discrimination → more discomfort → more physical activity) was statistically significant in the entire sample and among females, but not among males.

CONCLUSIONS

This is one of the first studies to demonstrate that discrimination is associated with physical health outcomes and behaviours via distinct pathways. Future investigations should further explicate the mediational pathways between discrimination and key health outcomes.

Moderators of the association between discrimination and alcohol consumption: findings from a representative sample of Brazilian university students

INTRODUCTION

Few studies about discrimination and patterns of alcohol consumption among youth populations have been conducted outside the United States addressing different types of discriminatory experiences, in addition to racially motivated events. This study investigated moderators of the association between discrimination attributed to single and multiple reasons and patterns of alcohol consumption.

METHODS

This cross-sectional study enrolled a representative sample (n = 1,264) of undergraduate students from Florianópolis, southern Brazil, in 2013. Analyses included adjustment of associations for covariates in ordinal logistic regression models and the examination of effect modification by common mental disorders, year of study and age.

RESULTS

Discrimination was reported by 65.8% of the students, and alcohol consumption, by 80.0%. Over half of the students reported being discriminated against for two or more reasons. The odds of alcohol-related problems were higher among lastyear students that reported discrimination (odds ratio [OR] = 1.9, 95% confidence interval [95%CI] 1.0-3.4) or multiple reasons for being discriminated against (OR = 2.3, 95%CI 1.3- 4.3), when compared to first-year students that did not report discrimination. For the whole sample, there were no associations between discrimination, discrimination attributed to multiple reasons and patterns of alcohol consumption (OR = 1.0, 95%CI 0.8-1.4; and OR = 0.9, 95%CI 0.5-1.6).

CONCLUSIONS

The effects of discrimination on the patterns of alcohol consumption are seen at a critical period in university life, specifically during the completion of undergraduate studies.

Self-reported racism and experience of toothache among pregnant Aboriginal Australians: the role of perceived stress, sense of control, and social support

OBJECTIVES

We hypothesized that the psychosocial factors perceived stress and sense of personal control mediated the relationship between self-reported racism and experience of toothache. We hypothesized that social support moderated this relationship.

METHODS

Data from 365 pregnant Aboriginal Australian women were used to evaluate experience of toothache, socio-demographic factors, psychosocial factors, general health, risk behaviors, and self-reported racism exposure. Hierarchical logistic regression models estimated odds ratios (ORs) and 95 percent confidence intervals (CIs) for experience of toothache. Perceived stress and sense of personal control were examined as mediators of the association between self-reported racism and experience of toothache. Social support was examined as a moderator.

RESULTS

Self-reported racism persisted as a risk indicator for experience of toothache (OR 1.99, 95 percent CI 1.07-3.72) after controlling for age, level of education, and difficulty paying a $100 dental bill. The relationship between self-reported racism and experience of toothache was mediated by sense of control. The direct effect of self-reported racism on experience of toothache became only marginally significant, and the indirect effect was significant (β coefficient=0.04, bias-corrected 95 percent CI 0.004-0.105, 21.2 percent of effect mediated). Stress was insignificant as a mediator. Social support was insignificant as a moderator.

CONCLUSIONS

The findings indicate that high levels of self-reported racism were associated with experience of toothache and that sense of control, but not perceived stress, mediated the association between self-reported racism and experience of toothache among this sample of pregnant Aboriginal Australian women. Social support did not moderate the association between self-reported racism and experience of toothache.